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Baroness Andrews: I am grateful to both noble Lords who have spoken. We all recognise the commitment of the noble Lord, Lord Colwyn, to his profession over the years. I have every sympathy with the intention behind Amendment No. 439A. I can reassure the noble Lord, Lord Colwyn, that the points he raises, both on dental public health advice and on dental membership of PCT executive committees are already covered by the PCT Executive Committee (Membership) Directions 2003.

Article 2(2) requires the executive committee to include at least one public health member. The directions further make clear that a public health member means a member of an executive committee who has qualifications and experience as a specialist in public health or who is a consultant in public health medicine or a consultant in dental public health.

Article 2(5) of the directions states that the professional members shall include medical practitioners, nurses and such professional members as, in the opinion of the trust, reflect the functions carried out by the trust. I am advised that the Local Health Board Constitution Regulations already make similar provision. Regulation 3 specifies the membership of a local health board, which includes a dental practitioner member. It also makes provision for the co-option from time to time of such other members as appears necessary or expedient for the performance by the board of its functions.

Shifting the balance of power in the NHS to the front line means leaving much decision-making to the PCTs, which themselves understand the requirements of the service at the local level. I would not want to be seen as micromanaging the NHS by putting such requirements on the face of the Bill. Directing PCTs about their governance arrangements is perfectly adequate.

My noble friend is absolutely right. There is an opportunity here for the first time for dental practitioners to work much more closely with the

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PCTs that will commission and direct work, plug the gaps in the service and work in partnership to develop the contract. I hesitate to mention field sites again, but they represent a way of testing new partnerships with PCTs, for example. That will be a way of developing shared values and understanding of the profession and the role it plays in general public health as well as in dental public health. I hope that with those assurances the noble Lord will be satisfied and will withdraw the amendment.

Lord Colwyn: I am grateful to the noble Baroness for that reply and for the remarks of the noble Lord, Lord Hunt. Over many years dentists have always felt left out of these matters. The reply was encouraging. I shall read what the noble Baroness said and reserve the possibility of returning to the matter at the next stage. In the mean time, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 440 not moved.]

Clause 167 agreed to.

Clause 168 [General dental services contracts]:

Baroness Noakes moved Amendment No. 441:


    Page 82, line 40, after "contract," insert—


"( ) the requirement for the contractor to collect charges for dental services under section 79 of the 1977 Act, to pay them to the Primary Care Trust or Local Health Board and to comply with financial control requirements regarding charges for dental services as specified by the Primary Care Trust or Local Health Board,"

The noble Baroness said: I shall speak also to Amendment No. 442. Both amendments are probing on the financial aspects of the new dental contract.

Amendment No. 441 amends Clause 168, which inserts new Section 28K into the 1977 NHS Act. It adds another area that general dental services contracts could cover; namely, the requirement for the dental contractor to collect dental charges, pay them to the PCT and comply with financial control requirements.

In moving from a system under which the dental practitioner is responsible for collecting and keeping dental charges, to the new system where risk related to that dental charging income is borne by the PCT, there are likely to be difficulties. The old system had many incentive effects that were not attractive but at least it placed the incentive for collecting charges fairly and squarely on the dental practitioner. If he did not collect, he would be out of pocket.

We are now moving to a new system where the dental practitioner will collect dental charges on behalf of the PCT and account to it for them. That raises a number of issues that I hope that the Minister will address. How will PCTs incentivise dental practitioners to charge for and collect all the income that should be collected? How will the PCT ensure that there is no fraud or error? Will the PCT have audit rights in relation to the dental practitioner's books and records? Will PCTs be able to lay down minimum standards of record-keeping?

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In addition, what costs are likely to fall on dentists for complying with any new requirements? The regulatory impact assessment makes it clear that most dentists are small businessmen. How will the Government ensure that any regulatory burden associated with the new scheme is minimised?

Amendment No. 442 deletes new Section 28N of the 1977 NHS Act, which will be inserted by Clause 168. New Section 28N allows the Secretary of State to have pretty complete control over payments made under general dental services contracts. Our amendment knocks that out of the Bill on a probing basis.

We had understood that the thrust of the new arrangements for dental services was to give new responsibilities to PCTs to provide primary dental services in their areas. That is much wider than their existing responsibilities. However, we do not understand how that can work in practice if the PCTs are hamstrung by remuneration terms laid down by the Secretary of State.

I assume that the moneys used by PCTs to pay for dental contracts are part of the much-vaunted 75 per cent of NHS money now being delegated to PCTs. What freedoms will the PCTs have in practice to use their financial resources to achieve better primary dental care services? For example, can they pay additional amounts if market forces locally require higher payments in order to achieve desired access levels? What freedoms, if any, will they have to use finance as a bargaining counter in setting satisfactory contracts? I beg to move.

Lord Colwyn: Very briefly, I want to say how incredibly complex the issue is. It has been a concern for dentists for many years. I remind the Committee that, at present, on people who are not exempt, GDPs collect 80 per cent of the full cost of the treatment. Bad debts exist; it is a problem. So far as I am aware, the new charging system for primary dental care is under discussion by Harry Cayton, the patients' tsar. I suspect that the Minister may not be able to answer on all the points raised, but the subject is no doubt evolving. Will the system be centralised, with overall central control, or will it purely be based in the PCTs?

3.45 a.m.

Baroness Andrews: I am grateful to the noble Lord. I cannot answer all those questions. I can answer some of them to some extent, but many of them will be answered by testing out systems of remuneration in the field sites themselves. Apart from anything else different ways of paying dentists are being looked at. I shall come to that.

I shall help by dealing with the amendment and setting out briefly how we intend to manage the transition from the current general dental services to local contracting and a GDS contract. Work is under way in the field sites to test new commissioning and remuneration models, among other innovations. The first field site draft contract templates will be

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available in January 2004. Learning from those sites will be ongoing beyond April 2005 for their lifespan. Additionally, some of the field sites are working with the PCTs and the strategic health authorities to develop monitoring and performance management systems to support the commissioning model. It was important—and this ran through Agenda for Change and the whole dialogue with the profession—that matters had to be tested first and there had to be robust mechanisms for learning from those tests.

Drawing on that programme and the personal dental services pilots, to ensure a smooth transition, the Department of Health has been working closely with the British Dental Association to develop a simple and robust base contract that all PCTs and practices will be able to put in place from April 2005. Under those arrangements, from April 2005, unless any local variations are agreed, the Dental Practice Board and its successor the special health authority will continue to pay dental practices contracting with the PCT broadly the same level of income for broadly comparable levels of activity—increased by any nationally agreed uplift following the DDRB's recommendations.

In answer to one of the specific questions asked by the noble Baroness, Lady Noakes, the collection of charges will be a contractual requirement, and the special health authority which will replace the DPB will verify the correct collection of charges and will report to the PCT. So there will be an audit mechanism in that form.

Amendment No. 441 seeks to make collection of patient charges and payment of them to the PCT a contractual matter under a GDS contract. Under the current arrangements, dentists collect patient charges from those patients liable to pay them and the NHS makes payments to dentists by way of remuneration, net of the charges collected. It is intended to continue this procedure under the new charging regime introduced under regulations made under a new Section 79 of the 1977 Act, which is inserted by Clause 179 of the Bill.

Subsection (3) of new Section 79 enables regulations to provide that sums which would otherwise be payable by a PCT, local health board or special health authority to providers be reduced by the amount of the charges authorised by the regulations. Harry Cayton, the director for patient experience and public involvement, is leading a review of patient charges for NHS dentistry. He will report next March. Part of that review will look at the ways of collecting patient charges. The current system works well and, from the NHS perspective, is simple to administer and has minimal bureaucracy. However, Agenda for Change reported that the profession would prefer to separate the direct link between patients' visits to the dentist and charge collection. The Government are sympathetic to that view, because we consider that collecting PCT charges and then remitting them to the PCT would be unnecessarily bureaucratic.

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While the technology is available to collect payments through smart cards, by mobile phone and so on, we will be interested in any of those ideas that may be put forward by Harry Cayton's review group on alternative ways to pay charges. We consider that dentists collecting charges and remitting them to the PCT will be unnecessarily bureaucratic and until the technology is available we intend that dentists and dental practices be paid for the provision of primary dental services net of the patients' charges collected. Therefore Amendment No. 441 does not find favour.

As regards the technical questions which the noble Baroness asked on Amendment No. 442, I shall have to write to her. However, perhaps I may explain that Section 28N(1) allows the Secretary of State or the Assembly to give directions regarding payments to be made under the new GDS contracts. Where directions are made, a GDS contract must require that payments are made under the contract in accordance with the directions.

New Section 28N replaces the existing system of remuneration for dentists providing general dental services under Section 35 of the 1977 Act. The rules setting out the remuneration are currently contained in the statement of dental remuneration. The SDR is a determination made by the Secretary of State or the Assembly under Regulation 19 of the National Health Service (General Dental Services) Regulations 1992.

Under Section 28N, payments in respect of any particular matter under the contract can be set on a national basis. Directions may relate to payments to be made by a PCT to a GDS provider or by a GDS provider to a PCT. Where there are no applicable directions, the parties to the GDS contract are free to determine the remuneration to be paid under the contract.

Subsection (3) sets out how the power to make directions may be exercised. It will enable directions to provide for payments to be determined by reference to the meeting of particular standards, for example. Directions may also be made in respect of individual practitioners and so would enable, for example, payments to be made in respect of a dental practitioner's maternity. That is why we need national scope for that.

Subsection (4) of new Section 28N recreates the existing requirements in Section 43B of the 1977 Act for the Secretary of State or the Assembly to consult representative bodies on remuneration matters. Under the new multi-professional GDS contract, this extends consultation rights to other groups whose members can become GDS providers—for example, representatives of other groups of dental healthcare professionals whose remuneration might also be affected.

Subsection (5) provides for directions to be made by regulations or by an instrument in writing and for directions made by an instrument in writing to be revoked or varied. Subsection (6) sets out some examples of what payments under this section include; namely, fees, allowances, reimbursements, loans and repayments.

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Representatives of the dental profession, in the interests of fairness to their members, are keen to preserve the ability to continue setting some payments under GDS contracts on a national basis. The payments which give the most concern are those in respect of a particular individual at the practice; for example, payments in respect of maternity. It is thought by the profession to be in the interests of fairness if such payments are determined nationally.

I realise that that was a detailed and complex explanation. However, I hope that the noble Baroness will accept it and withdraw her amendment.


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